The nurse is reviewing the patient's medical records which include history and physical, nurses' notes, imaging studies, and orders.
The nurse is asked to mark whether the assessment findings indicate that the treatment was effective or ineffective.
Which of the following options best describes the effectiveness of the treatment?
The treatment was effective.
The treatment was ineffective.
The treatment was partially effective.
It is too early to determine the effectiveness of the treatment.
The Correct Answer is C
Choice A rationale:
Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.
PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.
Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.
Choice B rationale:
Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.
Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.
Choice C rationale:
The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.
Choice D rationale:
It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1: Identify the desired dose and the available concentration. Desired dose: 500 mg of vancomycin
Available concentration: 500 mg per 100 ml
Step 2: Determine the volume needed to deliver the desired dose.
Since the available concentration is 500 mg per 100 ml, no further calculation is required. The volume needed to deliver 500 mg of vancomycin is already 100 ml.
Step 3: Calculate the infusion rate in mL/hr.
The medication needs to be administered over 1 hour.
Therefore, the infusion pump should be set to deliver the 100 ml of solution over 1 hour. Infusion rate = 100 ml / 1 hour = 100 mL/hr.
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
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